Living a full life with chronic conditions
Berri Wilmore, Howard University
Louis Steptoe, Archbishop John Carroll High School
Robin Gladden has looked death in the face.
It wasn’t due to her being raised by abusive, drug-addicted parents in a trauma-plagued community. Instead, she says it was because of mistakes and neglect by the health care system.
Gladden, 62, is a thyroid cancer survivor who also has diabetes, bursitis, high blood pressure, acid reflux and sciatica. She’s now a satisfied patient of Kaiser Permanente, which is like an accountable care organization (ACO) on steroids as it both treats and insures its patients.
More traditional accountable care organizations are groups of doctors and hospitals that coordinate the care of patients. Kaiser employs all of Gladden’s doctors and is the insurer she pays her insurance premiums to each month. That means Kaiser loses money if her conditions aren’t managed correctly.
This financial incentive is supposed to lower the cost and improve the quality of care.
“The idea is good: To give the doctors and hospitals a reasonable pot of money and put them, not insurers, in charge of how it is used to help patients,” says physician Adams Dudley, director of the Center for Healthcare Value of the University of California San Francisco. “This has led to some very beneficial interventions, like patient education programs to help people monitor and control their own diabetes, which can save money and improve outcomes.”
But sometimes, especially for organizations with a short-term view, giving doctors and hospitals a fixed budget has just resulted in them doing what some insurers do: “Deny needed care,” says Dudley, also a professor at UCSF’S medical school.
Kaiser Permanente says it has the numbers to show its model is working. Kaiser Permanente health plans were top-ranked for controlling high blood pressure, breast cancer screening and 19 other measures for commercial insurance plans, according to quality data out last year by the National Committee for Quality Assurance.
In September, the National Committee for Quality Assurance’s Health Insurance Plan Ratings for 2017-18 rated Kaiser Permanente health plans as among the nation’s top performers for consumer experience, prevention and treatment. NCQA’s annual report rates more than 1,000 health plans, including Medicare, Medicaid and Private (commercial), on a 0-to-5 scale, with 5 being the best.
Only 15 health plans in the country – about 1% - were given a 5 out 5 this year. Kaiser Permanente had six of them, which was more than any other organization. All of Kaiser’s plans scored 4.0 or higher for overall care.
ACOs haven’t been able to “break sharply from the mainstream of American medicine,” says Dudley. “As a result, the performance of Kaiser and similar organizations isn’t much different than average.”
In California, Dudley says Kaiser ranks slightly better than average, but not by much and rarely are they the best at anything.”
Caravan Health, a health care consulting firm that represents ACOs, released data recently showing that its clients saved more than $28 million in 2016 while the others who weren’t clients in a Medicare pilot program increased spending by $23 million.
Overall, ACOs have “been successful in important ways,” says Tim Gronniger, Caravan’s senior vice president for strategy.
More similar to the Kaiser model where the insurer is part of the group, nearly 20% of Medicare patients are in ACOs that are either part of a permanent CMS program or in federal pilot projects. says Gronniger, former chief of staff at the Centers for Medicare and Medicaid Services (CMS) in the Obama Administration.
There have been dramatic increases in quality almost uniformly across ACOs, says Gronniger.
“If you had expectations that they were going to solve American health care cost in five years,” that hasn’t happened, Gronniger acknowledged. But there’s been progress, including big jumps in the quality of care Medicare patients receive and unprecedented collaboration between health care providers, he says, and “that to me counts as successful,” he says.
Gladden has nothing but good things to say about the quality of her Kaiser care. It’s her experiences outside of Kaiser that have turned her into a believer in both Kaiser and wellness. She even hopes to publish a healthy eating cookbook.
Gladden’s diabetes started after a previous doctor suggested that she cut Diet Pepsi out of her diet and begin drinking juice instead. As it turned out, Gladden was pre-diabetic, and the recommended juice was loaded with sugar.
The juice advice caused her to be one of the many people in her family to develop diabetes. Growing up, Gladden lived with her grandparents, and while she lived with them her grandfather was a chef, so she ate well and she ate often.
When she moved back in with her mother, though, she took on the role of providing for her younger siblings. But being a child herself, they had to settle for Spam and Spaghetti-O’s for dinner every Thursday.
The high blood pressure that she developed while eating poorly in her younger years eventually became just one of her many ailments.
Several years before the bad juice advice, Gladden found herself hoping to pass out from the pain after she suffered from a calcium deficiency after surgery.
After being diagnosed with thyroid cancer, Gladden had her thyroid removed. While in the hospital, none of the people who saw her before her surgery realized that her high blood pressure medicine had a calcium blocker, and both her pain medication and antibiotics included calcium.
When she arrived to the hospital, they attempted to give her liquid calcium, not realizing that her body could not maintain medicine. At first, the symptoms were bearable: Crossed eyes and Charley horses. But soon her hands were cramping so badly that she couldn’t see.
Within two days, Gladden was terrified for her life. Despite her pain, she says, “the nursing staff ignored my cries for help.”
Eventually, her body was pulling calcium from her other muscles. This left her with a swollen tongue, and eyes that crossed so badly that it hurt to open them.
“I know what it feels like to be dying a painful death,” says Gladden.
The doctor who gave Gladden the juice advice was part of her former health insurance’s network. Although she was a member of Kaiser by the time she was diagnosed with cancer, she was at an unaffiliated Washington hospital when the problems occurred. Kaiser owns dozens of hospitals on the West Coast, primarily California, but only partners with them on the East Coast.
Primary care physician, Sos Mboijana, has treated Gladden at Kaiser Permante’s Capitol Hill office for the past 10 years. When she first went to him, Gladden sat down with 10 pages of notes she had taken about her various conditions. After all of her mishaps, she wasn’t taking any chances.
Now, thanks to his treatment and attention to detail, all of her conditions are under control.
“That’s someone who’s engaged,” she says. “That’s someone who is connected.”
Enjoying a full life while being treated for several chronic conditions is possible, as students learned during a visit to the Capitol Hill offices of the giant health consortium. Dr. Sos Mboijana of the Mid-Atlantic Permanente Medical Group explored a variety of topics with students and led a tour of facilities. The board-certified internist and graduate of Howard University College of Medicine also introduced two of his patients — Robin Gladden and Elfatih Abusa -- who volunteered to discuss their medical challenges.